Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part B billed carotid artery screening billed on dates of service from January 1, 2023 through May 31, 2025. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

The Carotid arteries are major vessels that extend from the aorta up through the neck on either side. Both the right and left carotid arteries divide into two branches in the neck, known as the internal and external carotid arteries. The internal carotid supplies the brain with oxygenated blood while the external carotid artery further divides into seven branches that supply blood to the face and neck. These arteries carry oxygenated blood from the heart to the brain, and the development of atherosclerotic disease can impair blood flow leading to ischemic events. The development of signs, carotid bruit, or symptoms would warrant additional investigation of the carotid arteries with ultrasonography. These conditions include atherosclerosis leading to stenosis, carotid artery aneurysm, transient ischemic attack (TIA), and stroke.

Conditions can be identified by providers through neck examinations using a stethoscope to assess for sounds of blood flow disturbance, also known as a bruit, which results from the narrowing of the carotid artery and development of turbulent flow. Some individuals are unaware of issues involving the carotid arteries, as symptoms often lack severity or are absent entirely. Instead, the first sign of disease for most is a TIA or stroke.

Cerebrovascular arterial study testing methods include real-time duplex scans; and doppler ultrasound waveform with spectral analysis. Providers may perform diagnostic testing to determine the presence of arterial disease.

Medicare Part B covers carotid artery testing in certain circumstances for select indications. Non-invasive vascular studies done for screening purposes without signs or symptoms of disease, are considered not reasonable and necessary and are therefore non-covered by Medicare.

Inappropriate carotid artery screening/testing has been an ongoing area of focus for the Office of the Inspector General (OIG) and its work. The SMRC did complete data analysis and medical record reviews in June 2021 and again in April 2023, on claims billed with CPT code 93880 “duplex scan of extracranial arteries; complete bilateral study”. The SMRC identified overall claim error rates of 52% and 57%.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record review activities on claims billed with CPT code 93880 for date of service January 1, 2023 through May 31, 2025. The SMRC will perform medical record review on supporting documentation, to determine if select Part B claims for carotid artery screening were reasonable and necessary.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. PLEASE NOTE: It is the responsibility of the billing provider to obtain and forward for review all documentation from the ordering/referring provider that confirm all medical necessity criteria have been met.
2. Physician/Non-Physician Practitioner (NPP) order or evidence of intent to order
3. Documentation supporting the diagnosis code(s) required for the item(s) billed such as progress notes/H&P
4. Progress notes from the ordering and/or referring provider describing and supporting the covered indication along with signs and symptoms for the diagnosis code(s) billed
5. Carotid ultrasound results and other pertinent test results and interpretations, including prior relevant studies with both normal and abnormal findings
6. Providers and/or suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available. Please include a signature log or signature attestation for any missing or illegible signature within the medical record
7. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
8. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
9. Medical record documentation to support national and local requirements
10. Any other supporting/pertinent documentation
11. Documentation to support the code(s) and modifier(s) billed
12. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation

References

Social Security Act (SSA), Title XI

• Section (§)1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• §1815(a) Payment to Providers of Services
• §1833(e) Payment of Benefits
• §1834(m)(4)(F) Special Payment Rules for Particular Items and Services
• §1842(p)(4) Provisions Relating to the Administration of Part B
• §1861(ddd)(1) Additional Preventive Services; Preventive Services
• §1861(s)(2)(K) Miscellaneous Provisions (Definitions of Services, Institutions, etc.)
• §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• §1869(f)(1)(B) Determinations; Appeals
• §1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• §1893(f)(7)(A)(B) (i-iv),(h)(4)(B) Medicare Integrity Program

Title 42 Code of Federal Regulations (CFR)

• §410.32 Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
• §410.33 Independent Diagnostic Testing Facility
• §410.64 Additional Preventative Services
• §411.15(k)(1) Particular Services Excluded From Coverage
• §424.5(a) Basic Conditions

Public Law

• Coronavirus Aid, Relief, and Economic Security (CARES) Act effective March 27, 2020. Retrieved from https://www.congress.gov/bill/116th-congress/house-bill/748/text

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)

Internet Only Manuals (IOM), Medicare National Coverage Determination Manual (NCD), Publication (Pub.) 100-03

• Chapter (Ch). 1, Part 1, §20.17 Noninvasive Tests of Carotid Function

IOM, Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Ch. 6, §20.4 Outpatient Diagnostic Services
• Ch. 15, §80.6.1-80.6.4 Requirements for Diagnostic X-ray, Diagnostic laboratory, and other Diagnostic tests
• Ch. 16, §20 General Exclusions from Coverage

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch.13, §10.1 Billing Part B Radiology Services and Other Diagnostic Procedures
• Ch. 13, §20 Payment Conditions for Radiology Services
• Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
• Ch. 30, §50 Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)
• Ch. 35, Independent Diagnostic Testing Facility (IDTF)

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3, §3.2.3.2 Time Frames for Submission
• Ch. 3, §3.2.3.3 Third-party Additional Documentation Request
• Ch. 3, §3.2.3.4 Additional Documentation Request Required and Optional Elements
• Ch. 3, §3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3, §3.3.2.1 Documents on which to Base a Determination
• Ch. 3, §3.3.2.4 Signature Requirements
• Ch. 3, §3.6.2.2 Reasonable and Necessary Criteria
• Ch. 3, §3.6.2.4 Coding Determinations
• Ch. 10, §10.2.2.4 Independent Diagnostic Testing Facility (IDTFs)
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• NCCI Policy Manual for Medicare Services, Effective January 1, 2020. Chapter 11, Section I. Cardiovascular Services

Local Coverage Determination (LCD)

• L33627 Non-Invasive Vascular Studies
• L33695 Non-Invasive Extracranial Arterial Studies
• L33910 Independent Diagnostic Testing Facility (IDTF)
• L34045 Non-Invasive Vascular Studies
• L35397 Non-Invasive Cerebrovascular Arterial Studies
• L35448 Independent Diagnostic Testing Facility (IDTF)
• L35753 Non-Invasive Cerebrovascular Studies

Local Coverage Article (LCA)

• A52992 Non-Invasive Cerebrovascular Arterial Studies
• A53252 Independent Diagnostic Testing Facility (IDTF)
• A56697 Non-Invasive Vascular Studies
• A56758 Non-Invasive Vascular Studies
• A57592 Non-Invasive Cerebrovascular Studies
• A57670 Non-Invasive Extracranial Arterial Studies
• A57807 Independent Diagnostic Testing Facility (IDTF)

Other

• Medicare Learning Network, MLN Matters MM6563. Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs). Effective April 1, 2010
• Medicare Learning Network, MLN Matters MLN909060. Independent Diagnostic Testing Facilities (IDTF). October 2022
• American Medical Association (AMA). (Current Procedural Terminology (CPT)
• American Academy of Professional Coders (AAPC)
• ICD-10-CM Official Guidelines for Coding and Reporting. Updated April 1, 2023, and April 1, 2025

Last Updated Jul 31, 2025